Strokes: progressive stroke pathway

6. TIA Services

Many people who develop mild or transient symptoms which might represent a TIA or mild stroke do not require immediate admission to hospital but do need specialist assessment by a clinician experienced in stroke care, early access to investigations and same day initiation of treatment to reduce the risk of a disabling stroke.

TIA services aim to offer these functions flexibly and provide access to support to reduce long-term risks and optimise the person's physical, psychological and social outcomes.

These services may be delivered in a variety of settings including, but not limited to, specialist TIA outpatients' clinics. However, people with suspected TIA can also be supported effectively through the provision of services within ambulatory care units, stroke units, or through rapid inpatient ward reviews. A proportion of patients with TIA are seen in an Emergency Department. These models of care, so long as they are supported by stroke specialists and have early access to investigations, or backup from a TIA clinic, can provide excellent care which minimises the risk of further stroke.

The Scottish Stroke Care Audit does not fully capture or monitor routinely activity which takes place outside of TIA clinics as it has proven challenging to capture data in these more varied settings. This should be addressed to enable us to understand and compare all models of care for people with TIA.

The performance of TIA clinics is currently monitored by the Scottish Stroke Care Audit which measures the proportion of patients seen in the TIA clinics within 4 days of referral. Whilst the majority of services meet the standard of 80%, there remain opportunities for improvement and to address variation.

As the risk of recurrent stroke is higher in the first day or two following a TIA, the faster a person can be seen the better. Therefore, the Scottish Stroke Improvement Programme will work with services across Scotland to minimise delays.

At present, the Scottish Stroke Care Audit measures the referral time to TIA services, but there is an opportunity to look in more detail at the care for people who have experienced a TIA. Therefore, development of a TIA bundle including times to important investigations and treatments should be included within the audit.

6.1 Specialist assessment

Specialist assessment for people with suspected TIA helps to expedite additional imaging where this is necessary and ensure that a diagnosis and treatment plan is refined and tailored to the individual's needs. This should take place in a timely manner, as specified by relevant clinical guidelines.

Where in-person specialist assessment cannot always be rapidly available, TIA services should consider how targeted access to local or remote stroke specialists (for patients meeting agreed criteria) can minimise delay to time-sensitive interventions.

Due to the Covid-19 pandemic many NHS boards had started to incorporate virtual assessments using telephone and Near Me into their assessments. This more flexible approach has led to reduced waiting times for specialist input in some areas. It is important to ensure that where virtual assessments are performed, patients should have the same access to rapid investigations and immediate secondary prevention as those who are seen face-to-face.

6.2 Investigations

People with suspected TIA or minor ischaemic stroke require timely access to investigations to confirm a diagnosis and guide treatment.

High risk TIAs and patients with uncertain presentations may be assessed as inpatients, and so rapid access to necessary radiology and cardiac investigations should be available in both outpatient and inpatient settings. There should be a robust system in place to ensure that the results of radiology and cardiac investigation results are available rapidly and are flagged to the responsible clinicians.

Full details of access to investigations for people with suspected TIA or stroke is outlined in Section 7.3: Access to imaging and other investigations.

6.3 Treatment and care

Where necessary, people seen in TIA services should be able to rapidly access appropriate support from a Multi-Disciplinary Team including speech and language therapy, occupational therapy, clinical psychology, orthotics, ophthalmology and orthoptics.

Some patients seen in TIA services turn out not to have had a TIA or stroke. Alternative pathways should be available if input is required from another specialist service. There should also be a system for rapid feedback to referrers when a person would not benefit from attendance at a TIA service, and clear communication of an alternative pathway or approach.

For people who are identified as having had a TIA, treatment involves access to secondary prevention medication and advice. All NHS Boards should therefore have accessible pathways and secondary prevention guidelines for TIA patient management, which should be up-to-date and responsive to change in the evidence base. These should ensure that:

• For TIA (with full recovery) antiplatelet agents and a statin should be commenced immediately (as per local guidance, including any necessary investigations) pending specialist review, unless specialist review is immediate.
• Guidelines should recommend which secondary prevention medication to prescribe but should also have a plan for situations where medication should not be stopped (e.g., for some cases - anticoagulants after TIA).
• Secondary preventative medications should be immediately available e.g., from ward stock, hospital pharmacy or written prescription to take straight to a 24/7 chemist.

People who have experienced a TIA or minor stroke may also require advice or onward referral to support them in their longer-term self-management. The following should be available from the TIA service:

• Referral to addiction support teams
• Ongoing driving advice and referral to the Scottish Driving Assessment Service when needed
• Recommendations to optimise physical activity and reduce sedentary behaviour, including referral to exercise services where appropriate
• Referral to Dietetics
• Vocational advice and support
• Recommendations to support emotional and psychological wellbeing including referral to psychological services where appropriate

Communication between health professionals following TIA assessment is important. There should be a rapid electronic communication system back to the referrer following assessment in a TIA service. If using a traditional dictated letter system, then the letter should be sent electronically and within 48 hours of the specialist assessment.

It is important that referrers are made aware of individual treatment targets:

• Remote blood pressure monitoring should be available where required e.g., FLORENCE programme or 24-hour ambulatory monitoring
• Selected patients may benefit from more aggressive lipid management aiming for lower LDL targets - where appropriate, pathways should be in place for this e.g., a pharmacist led stroke lipid clinic, primary care follow up system.
• Furthermore, any request to referrer to make urgent prescribing changes or other key changes to management should be transmitted immediately.

Following discharge from TIA services, patients who have experienced TIA or minor stroke should receive lifelong follow-up in primary care and long-term conditions monitoring. This will require ongoing education to support primary care professionals with:

• Current best practice for longer-term care of TIA or stroke survivors
• Managing stroke in people with co-existing conditions
• Current guidance and pathways for referring a person back to stroke services

Follow up appointments for people who have experienced TIA should be available when needed, potentially through the TIA clinic or a stroke liaison nurse team.

6.4 Recommendations

1. People with suspected TIA should have specialist assessment by a clinician experienced in stroke care, early access to investigations and same day initiation of treatment to reduce the risk of further stroke.

2. Where in-person specialist review cannot always be rapidly available, TIA services should consider how to enable access to local or remote stroke specialists for patients meeting agreed criteria.

3. There should be appropriate pathways in place for onward referral of people who have had neither stroke nor TIA but require input from another specialist service.

4. All NHS Boards should have accessible pathways and secondary prevention guidelines for TIA patient management.

5. TIA services should support the following, where required:

• Referral to addiction support teams
• Ongoing driving advice and referral to the Scottish Driving Assessment Service when needed
• Recommendations to optimise physical activity and reduce sedentary behaviour, including referral to exercise services where appropriate.
• Referral to Dietetics
• Recommendations to support emotional and psychological wellbeing including referral to psychological services where appropriate
• Vocational advice and support

6. The Scottish Stroke Care Audit should develop a TIA bundle which takes account of the varied models of providing care for people with TIA.